NICOLE M. JACK PA-C
NPI 1083104137
Physician Assistant in Pontiac, IL

Q: What is Nicole Jack's NPI number?

The NPI number for Nicole Jack is 1083104137. It was assigned to this individual provider in the NPPES registry on May 15, 2018.

Q: What is Nicole Jack's specialty?

The primary specialty registered for this NPI is Physician Assistant with taxonomy code 363A00000X.

Q: When was this NPI record last updated?

The NPPES record for Nicole Jack was last updated on June 18, 2018. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 8 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since May 15, 2018PECOS EnrolledAccepts Medicare Assignment

72.14/100

CMS Quality Rating

2500 W REYNOLDS ST, PONTIAC, IL 61764(815) 844-5343(815) 844-5715 Get Directions Write a Review

NPPES record last updated: June 18, 2018. Verified against the NPPES registry weekly; last sync: August 09, 2026.

Record update history: Jun 18, 2018, May 15, 2018 (2 updates tracked since 2018).

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About Nicole M. Jack Pa-c NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

NICOLE M. JACK PA-C (NPI 1083104137) is an individual physician assistant in Pontiac, Illinois, licensed in Illinois (085006579) and active in the NPI registry since May 2018. She is enrolled in Medicare PECOS, is affiliated with Memorial Medical Center, and is a graduate of Other (2017).

NPPES Registry Identity

NPI1083104137

Entity TypeIndividualFemale

Primary Taxonomy363A00000X

Provider Legal NameNICOLE M. JACKCredential: PA-C

Location Address2500 W REYNOLDS STPontiac, IL 61764

Mailing Address2500 W Reynolds StPontiac, IL 61764-9774 · (815) 844-5343 · Fax (815) 844-5715

Phone(815) 844-5343

Fax(815) 844-5715

Sole ProprietorNo

Medical School CMSOtherGraduated 2017

Enumeration DateMay 15, 2018

Last NPPES UpdateJune 18, 20182 updates tracked since enumeration

✔ NPI 1083104137 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPhysician AssistantPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363A00000X

License✔ Licensed in IL · 085006579

Definition

A physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and is practicing within the scope of that license. Physician assistants are formally trained to perform many of the routine, time-consuming tasks a physician can do. In some states, they may prescribe medications. They take medical histories, perform physical exams, order lab tests and x-rays, and give inoculations. Most states require that they work under the supervision of a physician.

2500 W REYNOLDS ST, Pontiac, IL 61764

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Nicole M. Jack Pa-c is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID7810242195

PECOS Enrollment IDI20180611002269

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Areas of Expertise CMS Part B claims 2

Services this provider delivered to Medicare fee-for-service patients, from the CMS Medicare utilization data. Higher counts generally reflect more experience with a service; care delivered outside Medicare is not included.

Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more 99214

This is a routine check-up for patients who have previously visited our clinic. It involves a comprehensive review of your health and any ongoing treatments. The consultation lasts between 30-39 minutes, allowing enough time to discuss any concerns.

68 services61 patients

Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more 99213

This is a routine visit for patients who have already been seen by the healthcare provider. During this approximately 20-29 minute appointment, your health status will be evaluated and any necessary treatments or tests will be discussed. It's a chance to address any health concerns you may have.

26 services24 patients

Hospital Affiliations CMS Care Compare

Hospitals where this provider delivers care, identified from recent Medicare claims and place-of-service records.

Memorial Medical Center

Acute Care Hospitals · Springfield, IL

2/5 CMS rating

OwnershipVoluntary non-profit - Private

CMS Certification Number140148

Location701 N First StSpringfield, IL 62702 · Sangamon County

Emergency services Birthing friendly

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 61764 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$85.71 typical visit price

range $54.80 – $168.44

Typical copayment $21.42 (range $13.70 – $42.11)

Most-billed visit code 99203

Established Patient

$68.64 typical visit price

range $17.16 – $136.56

Typical copayment $17.16 (range $4.29 – $34.14)

Most-billed visit code 99213

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Medicare Quality Performance CMS QPP · MIPS

Performance in the CMS Quality Payment Program: the MIPS final score across four weighted categories, and the individual quality measures reported to Medicare.

72.14/100

MIPS Final ScoreMerit-based Incentive Payment System · CMS Quality Payment Program

Scored as part of a group practice

Quality

74.96

Improvement Activities

Cost

53.06

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

EMILY RUFF

Occupational Therapist